A resident with vascular dementia, agitation, and anxiety received PRN lorazepam for anxiety, but the order was not limited to 14 days and lacked a documented rationale for extended use or a specific duration. The MAR showed repeated use of the medication, and the DON stated the order was missed getting the continued order.
A resident with dementia and psychotic disturbance was re-admitted on Zyprexa after the facility had previously completed a successful GDR and discontinued it. The facility did not follow up on why the hospital restarted the antipsychotic, and the record showed no behaviors or other documented clinical indication for continued use. The DON stated she was unsure why the medication was restarted and believed the resident did not need it.
A resident with vascular dementia, anxiety, and major depressive disorder had orders for Buspirone, Trazodone, and Paroxetine, but the facility did not document resident-specific targeted behaviors or monitoring for the psychotropic medications. The care plan did not include specific behavior-focused interventions for all three medications, and the MDS/DON could not find supporting behavior charting when surveyed.
The facility failed to document adequate behavioral monitoring for two residents receiving psychotropic medications. One resident with anxiety and depression was ordered Trazadone and Fluoxetine, and another resident with Alzheimer’s disease, dementia, and depression was ordered Venlafaxine HCl; however, the DON stated the facility only monitored antidepressants if depressive behaviors appeared and had no further behavioral monitoring documentation for either resident. The record also showed a GDR recommendation for Effexor that was not addressed.
Incomplete Assessment for Psychotropic Medication Use: A resident with depression, anxiety, and insomnia was receiving three antidepressant medications, but the medical record did not contain a comprehensive assessment for their use. The MDS CAA for psychotropic drug use was blank, and although hourly sleep studies were documented on the TAR, there was no additional documentation showing a comprehensive insomnia, depression, or anxiety assessment. The DON acknowledged the missing assessment documentation.
The facility failed to monitor resident-specific target behaviors for psychotropic medication use for three residents. One resident with dementia, anxiety, and traumatic brain dysfunction had quetiapine and sertraline orders, but the record lacked documentation of agitation, depression, or sleep concerns and staff said behaviors were not routinely tracked. Another resident with depression, anxiety, PTSD, and mood disorder was on quetiapine, trazodone, bupropion, and duloxetine, yet the chart had no behavior monitoring for sleep, depression, or anxiety. A third resident with vascular dementia, anxiety, and depression had quetiapine for agitation, but no agitation was documented and the DON could not find behavior monitoring.
Inadequate monitoring of psychotropic medication use was identified for two residents. One resident with dementia, psychotic disturbance, mood disturbance, and anxiety had orders for an antipsychotic, antidepressant, and PRN anti-anxiety medication, and targeted behavior monitoring was not established until the surveyor requested documentation. Another resident with an activated POA had orders for two antidepressants, and targeted behavior monitoring was also not in place until requested by the surveyor; the DON stated the facility could not locate prior monitoring and did not have a psychotropic medication policy.
A resident with dementia, anxiety, depression, CKD, DM, and hospice services was started on Seroquel for agitation and yelling out after family concerns, but the record did not show documented nonpharmacological interventions or assessment/rule-out of underlying medical conditions before the antipsychotic was ordered. Staff interviews described redirection and hand-holding, while the MAR behavior monitoring was incomplete and the NP noted no pain documentation.
Unnecessary Psychotropic Medication Use: Multiple residents were given psychotropic medications without adequate documented indication or supporting assessment. One resident with dementia received quetiapine with no documented behaviors, another resident received scheduled diphenhydramine-APAP for sleep and lorazepam without documented behaviors, a resident with schizophrenia had risperidone and sertraline without psychiatric follow-up or behavior documentation, and another resident received duloxetine for depression without supporting documentation in the record.
Two residents receiving psychotropic medications had inadequate behavior monitoring. One resident with dementia, anxiety, depression, wandering, and aggression had TAR entries that did not match progress notes and often lacked the required behavior codes, while another resident with Alzheimer’s disease and anxiety had scheduled clonazepam and PRN lorazepam given with little or no documented target behaviors, including vague “Other” entries without explanation.
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